Comparison of two procedures for laparovaginal hysterectomy: a randomized trial

doi:10.1016/S0301-2115(99)00221-3

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 90, Issue 1, May 2000, Pages 31-36

https://doi.org/10.1016/S0301-2115(99)00221-3 Get rights and content

Abstract

Objective: To compare peroperative parameters of two variants of a laparovaginal hysterectomy in surgical management of gynecological conditions. Methods: A prospective randomized study of 70 laparovaginal hysterectomies performed by the same two surgeons for disease of female pelvic organs. The following criteria were studied: indication for surgery, previous surgery, duration of the procedure, recovery, hospital stay, blood loss, tissue damage markers, hysterectomy proportions and complication incidence. Statistical analysis was performed using the non-parametric χ²-test and non-parametric Fischer’s exact probability test when appropriate, with a level of significance P=0.05. Results: Totals of 38 (54.3%) laparoscopy-assisted vaginal and 31 (45.7%) vaginally assisted laparoscopic hysterectomies were performed for fibroma as the main indication. Conversion to laparotomy was applied in only one patient. The VALH group (P=0.01) showed both fewer procedures and shorter hospital stay with insignificant blood loss. Conclusion: The two variants of a laparovaginal hysterectomy appear to be safe and appropriate, effective procedures for women with gynecological conditions. Furthermore, vaginally assisted laparoscopic hysterectomy has been shown to be superior to laparoscopy-assisted vaginal hysterectomy in terms of shorter operating time and greater palliative effect upon the complex of uterosacral ligaments. Laparoscopic surgery can alter the relationship between vaginal and abdominal hysterectomy.

Introduction

Hysterectomy is the most common major gynecological surgical procedure in the Czech Republic. Approximately 20 000 hysterectomies are performed annually. In women under 65 years of age, only 28% of hysterectomies were performed using a vaginal approach in the 1980s [1]. In the United States, 70% of hysterectomies are performed using an abdominal approach [2].

Laparoscopic hysterectomy (LH) is one of the most frequently performed major laparoscopic procedures. Laparoscopy-assisted hysterectomy has a multitude of modifications making it almost impossible to compare published results accurately. A review of the literature in Medline (1994–1998) reveals such a number of definitions that we found at least 18 different terms for the laparoscopic approach to hysterectomy. Several authors improved their terminology with growing experience. Nezhat et al. [3] described a group of definitions when identifying various degrees of laparoscopic and vaginal dissection, according to seven basic steps of hysterectomy (Table 1). Many gynecological surgeons turn their attention to laparovaginal hysterectomy (LVH), particularly to laparoscopy-assisted vaginal hysterectomy (LAVH), finding it safer and shorter in operation time than the laparoscopic hysterectomy [4], [5], [6], [7]. In our view, laparoscopic hysterectomy can be considered as a substitute for abdominal, not vaginal hysterectomy. The benefit to patients should be first taken in mind, even if the extent of laparoscopic and vaginal dissection is based on the surgeon’s preference and experience with laparoscopic and vaginal surgery.

For this reason we decided to compare peroperative parameters of the two variants of laparovaginal hysterectomy.

Section snippets

Material and methods

A randomized prospective study was undertaken at Baby Friendly Hospital Kladno on a total of 70 women having been hysterectomized laparovaginally through the LAVH or VALH procedure between October 1998 and February 1999. Patients were selected consecutively upon the physical, ultrasound and biopsy examinations, being randomized by a generator. The LVH was applied based on the complaints due to uterine myomas, endometriosis, menometrorrhagia, adnexal mass, and relapse of the cervical

Results

Laparovaginal hysterectomy was successful and completed in 69 women (successful laparoscopic procedure rate, 98.57%). In one patient, we decided to switch over to laparotomy, since, within the VALH preparation, we had to counteract a rupture of flat-scarred synechia in the vaginal vault, resulting from inflation of the pneumo-ocluder, a part of the Koh system. The suture was applied to stop bleeding from the scarified area.

One LAVH group-related patient experienced microembolism due to

Discussion

Laparoscopic hysterectomy (LH) is a fairly new surgical technique, described for the first time by Reich in 1989 [9]. It has received many controversial comments. Some authors think that the laparoscopy may assist in converting a potential total abdominal hysterectomy case to the vaginal route in a very limited number of cases, probably ranging from 2 to 15% [10], [11]. Other authors estimate a stronger expression of ratio changes [5], [6], [12]. Results from the studies of Chapron et al. [13],

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Cited by (13)

Laparoscopic-assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: A randomized clinical trial
2006, Journal of Minimally Invasive Gynecology
To compare laparoscopic-assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) for the treatment of endometrial cancer.
Randomized, controlled trial.
Randomized controlled trial (Canadian Task Force classification I).
Two gynecologic oncologic units of university hospitals.
Seventy-two women with endometrial cancer randomized to undergo either LAVH or TLH.
Total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, peritoneal washing, and systematic pelvic lymphadenectomy.
Parameters of technical feasibility (operating time of hysterectomy phase, estimated blood loss, perioperative complications) were considered as major statistical endpoints. Thirty-seven women were allocated to the LAVH arm, and 35 were allocated to the TLH arm. Mean total operating time was significantly shorter in the TLH than in the LAVH group (184.0 ± 46.0 vs 213.2 ± 39.4 minutes, p = .003). The hysterectomy phase was longer in the LAVH than in the TLH group only in overweight (77.9 ± 9.8 vs 68.1 ± 9.3 min, p = .005) and obese patients (87.7± 13.1 vs. 62.1± 9.9 min, p < .0001). The median estimated blood loss during hysterectomy was similar between groups. Intraoperative complications occurred in three (8.1%) patients in the LAVH group and in one patient (2.8%) in the TLH group (p = .61). No difference was found in the postoperative complication rate between women undergoing LAVH and those who had TLH (24.3% vs 17.1%, p = .56). Within a median follow-up period of 10 months (range 3–17 months), 2 patients in the LAVH group developed recurrent disease. No port site metastasis and no vaginal cuff recurrence were detected in either group.
Both LAVH and TLH can be performed successfully to manage endometrial cancer, with similar surgical outcomes. Obese patients benefit more from TLH than from LAVH in terms of shorter operating time.
Total laparoscopic hysterectomy: Body mass index and outcomes
2003, Obstetrics and Gynecology
This retrospective review of patients undergoing total laparoscopic hysterectomy examines whether differences in outcomes exist on the basis of body mass index (BMI).
All cases of total laparoscopic hysterectomy performed from September 1996 to July 2002 for benign diagnoses, and microinvasive cervical, early endometrial, and occult ovarian carcinoma were reviewed. There were 330 patients analyzed by BMI category (range, 18.5–54.1): ideal (n = 150) less than 24.9 kg/m², overweight (n = 95) 25 to 29.9 kg/m², and obese (n = 78) 30 kg/m² or more. Seven patients were converted to laparotomy (four ideal BMI, two overweight, one obese) leaving 323 (98%) for analysis. Mean age (50 years), height (65 in.), and parity (1.2) were similar, with 39% nulligravidas in each group.
Mean operating time (156 minutes), blood loss (160 mL), and length of hospital stay (1.9 days) did not vary by BMI group. Total complication rates (8.9%), and major (5.5%) and minor (3.4%) complication rates were similar in each BMI group. Urologic injury was observed in 3.1%, with two-thirds occurring in the first one-third of the patient series.
Total laparoscopic hysterectomy is feasible and safe, resulting in short hospital stay, minimal blood loss, and minimal operating time for patients in all BMI groups. The laparoscopic approach may extend the benefits of minimally invasive hysterectomy to the very obese, for whom abdominal surgery poses serious risk.
Surgical approaches in patients with endometrial cancer. Review of the literature
2003, Gynecologie Obstetrique et Fertilite
Trois voies d’abord chirurgicales sont décrites pour le traitement des adénocarcinomes endométriaux. Le but de cette étude est de faire le point sur les critères actuellement disponibles qui permettent de faire un choix. Nous avons revu les données disponibles dans la littérature (recherche Medline). Seules la laparotomie et la voie basse cœlio-assistée permettent la réalisation du bilan selon les critères de la FIGO (classification 1988). On ne dispose que d’une étude comparant de façon randomisée la laparotomie et la voie basse cœlio-assistée. La morbidité est moins importante par association. On manque de recul pour apprécier la survie qui ne paraît pas modifiée à court terme. Les autres études, non randomisées, montrent que la cœlioscopie est proposée à des patientes ayant un IMC plus bas et présentant des stades limités. Aucune étude randomisée n’a comparé la laparotomie à la voie vaginale seule. Cette dernière est généralement proposée pour des patientes ayant une comorbidité associée et présentant des stades limités. Dans ces circonstances, aucune différence de survie n’est mise en évidence. L’obésité ne représente une contre-indication absolue à aucune voie. Elle rend la chirurgie généralement plus complexe. L’existence d’une pathologie annexielle est, actuellement, un critère de choix en faveur de la laparotomie. Un utérus volumineux est une indication à une laparotomie. On n’acceptera une intervention par voie cœlio-assistée que si le volume est inférieur à 500 g et en l’absence d’infiltration pariétale utérine. La laparotomie est la voie de référence. La voie vaginale seule a ses principales indications dans le traitement des formes précoces ou lorsqu’il s’agit de la seule voie permettant d’opérer la patiente. La voie basse cœlio-assistée est une option pour les stades précoces. Elle n’est pas recommandée dès qu’une lésion annexielle ou infiltration pariétale sont suspectées. Il est contre-indiqué d’utiliser une voie d’abord à laquelle on n’a pas été formé.
Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO’s criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.
Surgical approach to hysterectomy for benign gynaecological disease
2023, Cochrane Database of Systematic Reviews
Surgical approach to hysterectomy for benign gynaecological disease
2015, Cochrane Database of Systematic Reviews
Body mass index and its role in total laparoscopic hysterectomy
2014, ISRN Obstetrics and Gynecology

View all citing articles on Scopus

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Original ArticleComparison of two procedures for laparovaginal hysterectomy: a randomized trial

Abstract

Introduction

Section snippets

Material and methods

Results

Discussion

J. Am. Assoc. Gynecol. Laparosc.

J. Am. Assoc. Gynecol. Laparosc.

Eur. J. Obstet. Gynecol. Reprod. Biol.

Lancet

Obstet. Gynecol.

Hysterectomy: a critical review

J. Reprod. Med.

A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy

Br. J. Obstet. Gynaecol.

Can laparoscopic assisted hysterectomy safely replace abdominal hysterectomy

Br. J. Obstet. Gynaecol.

Initial experience laparoscopic-assisted Doderlain hysterectomy

Br. J. Obstet. Gynaecol.

Laparoscopically assisted vaginal hysterectomy: report of 190 cases

J. Laparoendosc. Adv. Surg. Tech. A.

Laparoscopic hysterectomy

J. Gynecol. Surg.

Assessing the role of laparoscopically assisted vaginal hysterectomy in the every day practice of gynecology

J. Reprod. Med.

Original Article
Comparison of two procedures for laparovaginal hysterectomy: a randomized trial